It triggered a wide ranging inquiry headed by Lord Laming, who described it as the worst case of neglect he had ever heard of.

His year-long public inquiry identified social services departments at four London boroughs, two police forces, two hospitals, and a specialist children's unit who all failed to act when presented with evidence of abuse.

I remain amazed that nobody in any of the key agencies had
the presence of mind to follow what are relatively straightforward procedures

"In most cases, nothing more than a manager reading a file, or asking a basic question about whether standard practice had been followed, may have changed the course of these terrible events," Lord Laming said

In his report, he wrote: "The legislative framework is fundamentally sound - the gap
is in the implementation."

The peer said the greatest failure lay with senior managers and those in charge of staffing and financing these services.

But he believes the publicity during the inquiry had already caused some improvements.

His report proposed the national agency would report to a ministerial committee and attempt to improve co-ordination between groups responsible for child protection.

'Every service failed'

Health Secretary Alan Milburn said the relevant agencies had more than a dozen opportunities within 10 months to act to save Victoria Climbie but failed to do so.

"This was not a failing on the part of one service, it was a failing on the part of every service," he told the House of Commons in a special statement.